NICE guidance - insulin therapy in combination with oral hypoglycaemic agent (s) in type 2 diabetes

• NICE have previously issued guidance regarding the use of oral agent combination therapy with insulin (1):
  • combining basal insulin therapy and oral agent (s)
    • when starting basal insulin therapy:
      • continue with metformin and the sulfonylurea (and acarbose, if used)
      • review the use of the sulfonylurea if hypoglycaemia occurs
  • combining pre-mixed insulin and oral agent (s)
    • when starting pre-mixed insulin therapy (or mealtime plus basal insulin regimens):
      • continue with metformin
      • continue the sulfonylurea initially, but review and discontinue if hypoglycaemia occurs
  • combining insulin and pioglitazone
    • consider combining pioglitazone with insulin therapy for:
      • a person who has previously had a marked glucose-lowering response to thiazolidinedione therapy
      • a person on high-dose insulin therapy whose blood glucose is inadequately controlled. Warn the person to discontinue pioglitazone if clinically significant fluid retention develops
        
        
• Updated guidance contains minimal guidance with respect to oral agents and insulin (2):
  • for adults with type 2 diabetes starting insulin therapy, continue to offer metformin for people without contraindications or intolerance. Review the continued need for other blood glucose lowering therapies

Reference:

• (1) NICE (May 2008). Management of type 2 diabetes.
• (2) NICE (February 2022). Type 2 diabetes in adults: management